Taxane Followed by Anthracycline or Vice Versa

To the Editor I want to congratulate Joensuu and colleagues for their article in which they investigated the effect of adjuvant capecitabine in combination with docetaxel, epirubicin, and cyclophosphamide for early breast cancer. They reported that capecitabine with docetaxel, epirubicin, and cyclophosphamide did not prolong recurrence-free survival or overall survival compared with a regimen that contained only standard agents. Patients with triple-negative breast cancer had favorable survival outcomes when treated with the capecitabine-containing regimen in an exploratory subgroup analysis. Herein, I want to touch on the sequential order of taxane and anthracycline therapy in breast cancer. Pachmann et al hypothesized that a neoadjuvant regimen of a taxane followed by an anthracycline may result in a greater decline in the amount of circulating breast cancer cells than the regimen of an anthracycline followed by a taxane. The study showed that neoadjuvant chemotherapy with paclitaxel in patients with breast cancer interestingly causes the release of breast cancer cells into circulation, while at the same time reducing tumor size. In this study, during the applied combination therapy, 3 different phases were observed: an initial decline in the number of circulating tumor cells during the epirubicin-containing part of the regimen, followed by a steep increase during paclitaxel treatment, and a subsequent redecrease if a third regimen with the cyclophosphamide-methotrexate-fluorouracil combination was administered. This, in turn, might lead to longer-term survival benefit if the taxane is administered first in the neoadjuvant setting. Taken all together, I assume that giving a taxane first followed by an anthracyline as in the current FinXX Trial might show additional benefit with adjuvant capecitabine in patients with high-risk breast cancer.

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